Patient Intake Form – Dr. Andrea Sullivan

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Social Security number (Responsible Party) *

Phone *

Date of Birth *

Referred By:

EMERGENCY CONTACT *

First

Last

Employer Information

Occupation

Employer

Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

MEDICAL HISTORY

LIST HEALTH PROBLEMS/COMPLAINTS IN ORDER OF IMPORTANCE

Is this Condition due to injury for sickness arising out of your employment?

Have you had similar symptoms before?

If So, When?

Have you seen a Physician for the above Conditions?

If So, When? (copy)

Date of last Complete Physical Exam *

PRESCRIPTION HISTORY

Current Medications *

Nutritional Supplements, Herbs *

Serious Illnesses

Major Accidents

Do you use a Special Diet

Do you react to Certain Foods, Pollens or Animals? If so, List them Below:

List any Chemicals, Metals, Dusts or Fumes you are exposed to regularly and how you react to them.

How Frequently have you taken Antibiotics?

FAMILY HISTORY

Please indicate if any and which of family members have had any of the following condition(s):

Family History *

Allergies
Alcoholism
Asthma
Cancer
Diabetes
Epilepsy
Heart Disease
Thyroid Disorder
High Blood Pressure
Hypoglycemia
Kidney Disease
Nervous or Mental Disorder
Tuberculosis
Other Inheritable Condition
None

Have you had any of the Above? If so, which?

YOUR HEALTH HISTORY

Please indicate if any of the following condition(s)

Family History (copy) *

Back Trouble
Cataracts
Gall Bladder Disorder
Colitis/Diverticulitis
Liver Disease
Venereal Disease
Loss Of Sex Drive
Rheumatic Fever
Scarlet Fever
Hearing Loss
Visual Disorder
Cancer

Women

Menstrual Cycle Regular?

Length of Cycle?

Are You Pregnant?

Births?

Number of Pregnancies?

Miscarriages?

Abortions?

Have You Ever Used Birth Control Pills?

Dates?

When Was Your Last Pap Smear? (copy)

Results?

Do You Experience Premenstrual Symptoms?

What Are They And How Severe?

HISTORY OF VACCINATIONS (FOR CHILDREN ONLY):

TYPE/DATES

I UNDERSTAND THAT MY INSURANCE COMPANY MAY NOT REIMBURSE FOR THE EXPENSES INCURRED AT THIS OFFICE. I UNDERSTAND THAT I AM FULLY RESPONSIBLE FOR ALL DEBT.

PERSON PAYING FOR THE BILL (if not patient) *

First

Last

I UNDERSTAND THAT MY INSURANCE COMPANY MAY NOT REIMBURSE FOR THE EXPENSES INCURRED AT THIS OFFICE. I UNDERSTAND THAT I AM FULLY RESPONSIBLE FOR ALL DEBT. *

Signature

I understand a 24 hour advanced notice is required when canceling my appointment and if there is not a 24 hour notice given, I will be billed $65.00 for a late cancellation fee

I understand that if i do not keep my appointment and do not call to cancel or reschedule, I will be billed $75.00 for a no show fee. *

Signature

I understand that if i do not keep my appointment and do not call to cancel or reschedule, I will be billed $75.00 for a no show fee.

I understand that if i do not keep my appointment and do not call to cancel or reschedule, I will be billed $75.00 for a no show fee. *

Signature

Employer Information

MEDICAL HISTORY

PRESCRIPTION HISTORY

FAMILY HISTORY

YOUR HEALTH HISTORY

Women

HISTORY OF VACCINATIONS (FOR CHILDREN ONLY):

I UNDERSTAND THAT MY INSURANCE COMPANY MAY NOT REIMBURSE FOR THE EXPENSES INCURRED AT THIS OFFICE. I UNDERSTAND THAT I AM FULLY RESPONSIBLE FOR ALL DEBT.

I understand a 24 hour advanced notice is required when canceling my appointment and if there is not a 24 hour notice given, I will be billed $65.00 for a late cancellation fee

I understand that if i do not keep my appointment and do not call to cancel or reschedule, I will be billed $75.00 for a no show fee.

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